<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">


<!--    <div class="form-group">-->
<!--        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>-->
<!--        <div class="col-xs-12 col-sm-8">-->
<!--            <input id="c-name" data-rule="required" class="form-control" name="row[name]" type="text" value="{$row.name|htmlentities}">-->
<!--        </div>-->
<!--    </div>-->
    <div class="form-group">
        <div class="form-inline">
            <label class="control-label col-xs-12 col-sm-2">{:__('Account')}:</label>
            <div class="col-xs-12 col-sm-4">
                <input id="c-account" data-rule="required" class="form-control" name="row[account]" type="text" value="{$row.account|htmlentities}">
            </div>
        </div>
        <div class="form-inline">
            <label class="control-label col-xs-12 col-sm-2">{:__('Startingpaymentmonth')}:</label>
            <div class="col-xs-12 col-sm-4">
                <input id="c-startingpaymentmonth" data-rule="required" class="form-control" name="row[startingpaymentmonth]" type="text" value="{$row.startingpaymentmonth|htmlentities}">
            </div>
        </div>
    </div>

    <div class="form-group">
        <div class="form-inline">
        <label class="control-label col-xs-12 col-sm-2">{:__('Level')}:</label>
        <div class="col-xs-12 col-sm-4">
            <input id="c-level" class="form-control" name="row[level]" type="text" value="{$row.level|htmlentities}">
        </div>
        </div>
        <div class="form-inline">
            <label class="control-label col-xs-12 col-sm-2">{:__('Base')}:</label>
            <div class="col-xs-12 col-sm-4">
                <input id="c-base" class="form-control" name="row[base]" type="text" value="{$row.base|htmlentities}">
            </div>
        </div>
    </div>

<!--    <div class="form-group">-->
<!--        <label class="control-label col-xs-12 col-sm-2">{:__('Insuredplace')}:</label>-->
<!--        <div class="col-xs-12 col-sm-8">-->
<!--            <input id="c-insuredplace" class="form-control" name="row[insuredplace]" type="text" value="{$row.insuredplace|htmlentities}">-->
<!--        </div>-->
<!--    </div>-->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Status')}:</label>
        <div class="col-xs-12 col-sm-8">

            <div class="radio">
                {foreach name="statusList" item="vo"}
                <label for="row[status]-{$key}"><input id="row[status]-{$key}" name="row[status]" type="radio" value="{$key}" {in name="key" value="$row.status"}checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>
